Hoe is het u bevallen? Een onderzoek naar de ervaringen van vrouwen in de geboortezorg
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In response to a report that showed a relatively high number of perinatal mortality in the Netherlands, natal care became an important topic on the political agenda. The high number is partly due to the suboptimal functioning of natal care, because of a lack of communication and coordination between healthcare professionals. To improve this, the government-ordered Care Standard for Integrated Natal Care (Zorgstandaard Integrale Geboortezorg) was composed. This Standard was added to the national quality register of the Care Institute (Zorginstituut), which meant that all parties involved in natal care have an obligation to implement this Standard. Integrated natal care will only match properly with all the stakeholders, when it is communicated well and it is clear how it offers added value for the client. The goal of this master’s thesis was to contribute to the improvement of the implementation of integrated natal care, by gaining insight into the experiences of women in natal care. To reach this goal, a qualitative practice-oriented case study was done. Semi-structured in-depth interviews with pregnant women, or women that recently had a baby, were conducted. To get a deeper understanding of these experiences and the mechanism behind them, a theoretical framework constructed by the Netherlands Scientific Council for Government Policy (WRR) was used. The switch to an integrated form of care is a combination of changes in the field of healthcare professionals and centralizing the client, arranging the care around her. The theory that was used, as presented by the WRR, focuses on the tensions that exist within and between the groups of actors that are involved in these changes. In this thesis, the focus was on what they described as the ‘provision logic’ and the ‘client logic’, and the tensions within and between these logics. These logics refer respectively to the perspective of the professional, the provider of care, and the perspective of the client. The concepts that were used in the analysis of this thesis are: transfer, proto-professionalization, responsivity, learning effects, and exit, voice and silence. The results of this thesis showed that most women in natal care find it important that their healthcare professionals (mostly their midwife) engaged them in their care trajectory. They wanted to be informed properly every step of the way, to be able to voice questions or concerns, and to be able to make informed choices about their care. This was important during both pregnancy and labor. The amount of engagement women experienced during pregnancy, labor and postpartum, was dependent on the amount of room for involvement the healthcare professional provided and the personal connection they had with their healthcare professional. The amount of knowledge a woman had before starting the trajectory and during counseling moments with their healthcare professional, also played a role. A lack of room for engagement and feeling of agency could result in a more negative experience of natal care. Not all women voiced their questions or concerns. This could mean that healthcare professionals did not provide room for them to do so, but it could also mean that they were content with the care they were given and felt there was no need. However, some women also pointed out that they felt that a certain amount of assertiveness was needed to be heard by their healthcare professionals. It is important that healthcare professionals take into consideration that some women are less assertive or by other means less able to let themselves be heard. Lastly, women appreciated it if their input was noticeably used after they voiced dissatisfaction with the care they were provided. On the basis of these results, a few policy recommendations were made that could be taken into consideration with the implementation of integrated natal care. The first recommendation concerns transparency. To make sure all women are informed and therefore better able to be engaged in their natal care trajectory an online platform could be created. Here, they would be able to not only find information on pregnancy and labor, but also on the structure of natal care and the various healthcare providers that are involved in this. Secondly, the recommendation of the ‘3 good questions’. These three questions were drawn up by a patient interest group, to help women engage in their care trajectory. However, to ensure that women that are less able voice questions or wishes, these three questions can also be used by healthcare professionals. They can keep these questions in the back of their mind when counseling their clients, so that even if a woman does not explicitly ask these questions, she will still know the answer to them. The last policy recommendation relates to creating learning opportunities for the healthcare professionals. By making more use of methods for evaluating women’s experiences, they can keep adjusting the care and policy according to the needs of their clients. Going back to focusing on the client can also help all the involved stakeholders to reach consensus about the way integrated natal care should be implemented. The end goal is the same: added value for the client.